empirical assessment of lanius et al.s' 'functional mri of emdr in

Defence Research and Recherche et d6veloppementDevelopment Canada pour la defense Canada

DEFENCE POOVDEFENSE

Empirical assessment of Lanius et al.s'"Functional MRI of EMDR in Peacekeepers"a review of the EMDR literature and anannotated bibliography

Megan M. ThompsonLuigi Pasto DISTRIBUTION STATEMENT ADonald R. McCreary Approved for Public Release

Distribution Unlimited

Defence R&D Canada - TorontoTechnical Memorandum

DRDC Toronto TM 2002-025

July 2002

Canad20021023 098

"- Empirical assessment of Lanius et al.s''Functional MRI of EMDR inPeacekeepers', a review of the EMDR

* literature and an annotated bibliography

Megan. M. Thompson

Luigi Past6

Donald R. McCreary

0

0Defence R&D Canada - Toronto

Technical Memorandum


July 2002

0

Authors

"Megan M. Thompson, PhD

Approved by

Head, Command Ef ectiveness and Behavior Section

Approved for release by

K.M. Sutton

Chair, Document Review and Library Committee

© Her Majesty the Queen as represented by the Minister of National Defence, 2002

© Sa majest6 la reine, reprisent6e par le ministre de la Defense nationale, 2002

= • m i I i i i P6

Abstract

This report reviews a research proposal, the major objective of which is to assess the relationbetween PTSD (Post Traumatic Stress Disorder) and limbic, paralimbic, and prefrontal brainfunction as assessed with functional MRI (Magnetic Resonance Imaging), and to determinewhether an Eye Movement Desensitization and Reprocessing (EMDR) intervention causesthose structures to return to a normal mode of functioning. The proposed study secondarilyexplores the effectiveness of EMDR in reducing PTSD symptomatology. While the first andsecond objectives of the study may have scientific merit, the mandates of other fundingagencies would appear to be more appropriate for investigations of basic neuroscienceprocesses associated with brain functioning in PTSD (e.g., NSERC or CIHR). Importantly, acritical review of the EMDR research reveals that a great deal of controversy surrounds theeffectiveness of this therapy. EMDR has not been shown to be more effective than presentlyvalidated PTSD exposure-based therapies, and the eye movement component of EMDRappears to provide no therapeutic benefit. Finally, there is a lack of clarity around specificitems listed in the proposed budget. Given these concerns it is not recommended that thisproposal be funded at this time.

R sum

Le prdsent rapport passe en revue une proposition de recherche, dont l'objectif premier estd'6valuer la relation entre le SSPT (syndrome de stress post-traumatique) et les fonctionsc6rdbrales limbiques, paralimbiques et prdfrontales, en utilisant F'IRM fonctionnelle (imageriepar rdsonance magn6tique), et de d6terminer si le traitement de d6sensibilisation desmouvements oculaires et de retraitement (DMOR) permet A ces fonctions de revenir A unmode de fonctionnement normal. L'6tude propos6e explore aussi l'efficacit6 de laddsensibilisation des mouvements oculaires et du retraitement pour r~duire les sympt6mes duSSPT. Meme si le premier et le second objectifs de l'Ntude peuvent avoir des avantagesscientifiques, d'autres organismes de financement sembleraient plus approprids pour financerla recherche sur les processus de neurosciences 6lmentaires associ6s au fonctionnement ducerveau lors du SSPT (par exemple, le CRSNG ou les IRSC). Fait important, une revuecritique de la recherche sur la d6sensibilisation des mouvements oculaires et le retraitementr6v~le que ce traitement suscite beaucoup de controverse. I1 n'a pas 6t6 d6montr6 que lad~sensibilisation des mouvements oculaires et le retraitement constituent un traitement plusefficace du SSPT que les therapies d'exposition actuellement utilis~es A cette fin, et lacomposante mouvements oculaires du traitement DMOR ne semble avoir aucun effetth6rapeutique. Enfin, il y a un manque de clart6 en ce qui concerne certains postes inscrits aubudget propos6. Etant donn6 ces problýmes, il n'est pas recommand6 de financer cetteproposition pour le moment.


0

6

6

6

This page intentionally left blank.

6

6

6

6

6

6

6

jj DRDC Toronto TM 2002-025

6

* ~~Executive summary.........

This report reviews a research proposal recently submitted to the Department of NationalDefence for funding consideration. This proposal concerns the functional MRI (fMRI) ofbrain structures presumed related both with PTSD (Post-traumatic Stress Disorder) and withthe neural pathways assumed affected by EMDR (Eye Movement Desensitization andReprocessing) for PTSD in Peacekeepers.

The report is divided into 3 sections: review of the goals of the research proposal, review ofthe EMDR literature, and funding issues related to the research proposal. In addition, a morecomplete summary of the EMDR literature and an annotated bibliography of reviews of theEMDR literature are provided.

Research goals:

The initial stated aim of the proposal is the study of EMDR as a treatment for peacekeeping-related PTSD. However, the EMDR treatment - PTSD recovery aspect is actually a relativelysecondary issue throughout the proposal. Thus it is more difficult to justify Department ofNational Defence/Canadian Forces monies to subsidize this work or to justify the time andpsychological commitment of CF personnel suffering from PTSD.

The major objective of the proposed study, then, is to assess the impact of PTSD (PostTraumatic Stress Disorder) on limbic, paralimbic, and prefrontal brain structures usingfunctional MRI (Magnetic Resonance Imaging), and to determine whether an EMDRintervention causes those structures to return to their normal mode of functioning, while alsoreducing PTSD symptomatology. As the relation between EMDR treatment and changesamong the brain structures presumably identified with PTSD symptomatology has not beenestablished, it is difficult, therefore, to justify the use of EMDR as a vehicle to explorechanges in these brain structures. Moreover, while the mapping of changes in brain structureshas scientific merit, the mandates of other funding agencies would appear to be moreappropriate for investigations of basic neuroscience processes associated with brainfunctioning in PTSD (e.g., NSERC or CIHR).

Therapeutic effectiveness of EMDR

A review of the EMDR research reveals that a great deal of controversy surrounds theeffectiveness of this therapy. In general, reviews of the empirical EMDR literature find that:

1. EMDR is an effective treatment only when compared to no treatment or waitlist controlsor to non-specific therapies (e.g., biofeedback, relaxation);

2. EMDR is not more effective than exposure-based therapies, including stress inoculation,cognitive therapy techniques and prolonged exposure;

Thompson, M.M., Past6, L., McCreary, D.R.. 2002. Empirical assessment of Lanius et al.s' 'Functional MRI ofEMDR in Peacekeepers', a review of the EMDR literature and an annotated bibliography. IDRDC Toronto TM 2002 - 025. DRDC Toronto.

DRDC Toronto TM 2002-025 iii

3. Eye movements, or indeed any other alternating stimuli (e.g. therapist finger tapping) arenot responsible for treatment benefits.

Given the present controversy that surrounds the effectiveness EMDR therapy it does notseem prudent to fund research based upon its application to peacekeeping-related PTSDamong CF personnel. Requested Financial Support: The following issues with regard to thenature and dollar value of specific items in the request for financial support requireclarification.

Requested Financial Support: The following issues with regard to the nature and dollar valueof specific items in the request for financial support require clarification.

1. It is unclear on what bases the authors have allocated costs for the psychiatric assessments(1200.00 per assessment).

2. The identities of the individuals budgeted to receive remuneration for completing variouscomponents of the project should be specified, particularly if these individuals are also theauthors of the proposal.

Conclusion

The major objectives of this study are basic research rather than application to the bettermentof CF personnel coping with peacekeeping-related PTSD. Thus, other funding agenciesappear to be more appropriate sources of funding for this work. The effectiveness of EMDRappears tied to its exposure and cognitive reformulation components and unrelated to eyemovements. Thus, the use of EMDR will not produce a therapeutic benefit above those ofestablished, empirically validated PTSD therapies. Aspects of the proposed budget areunclear. At this point it does not seem prudent to invest in this research proposal.

iv DRDC Toronto TM 2002-025

* Sommaire

Le present rapport passe en revue une demande de financement d'une proposition derecherche r~cemment pr6sent6e au minist~re de la Deense nationale. Cette proposition derecherche porte sur l'&ude par IRM fonctionnelle (IRMf) des structures c~r6brales qui, dumomns le suppose-t-on, seraient li~es A la fois au SSPT (syndrome de stress post-traumatique)et aux voies neurales qui seraient touch6es par la ddsensibilisation des mouvements oculaireset le retraitement (DMOR) lors du traitement du SSPT chez les Casques bleus.

Le rapport est divis6 en trois sections : examen des objectifs de la proposition de recherche,revue de la littdrature sur la d6sensibilisation des mouvements oculaires et le retraitement et

* examen des questions financi~res li6es A la proposition de recherche. De plus, un r~sum6 pluscomplet de la littdrature portant sur le traitement DMOR ainsi qu'une bibliographie annot6esont pr~sent6s.

Objectifs de la recherche:

L'objectif premier de la proposition de recherche est l'6tude de la d~sensibilisation desmouvements oculaires et du retraitement (DMOR) lors du traitement du SSPT chez lesCasques bleus. Cependant, le lien entre le traitement DMOR et l'6limination du SSPT est enr~alit6 une question relativement secondaire tout au long de la proposition. Par consdquent, iiest plus difficile de justifier le financement de ces travaux par le minist~re de la Ddense

0 nationale/Forces canadiennes, le temps consacr6 A cette fin, ainsi que l'engagementpsychologique des memnbres des Forces canadiennes qui souffrent du SSPT.

L'objectif principal de l'6tude propos6e est donc d'6valuer l'impact du SSPT (syndrome destress post-traumatique) sur les fonctions c6r6brales limbiques, paralimbiques et pr~frontales,A l'aide de F'IRM fonctionnelle (imagerie par rdsonance magn6tique), et de d6terminer si une

10 intervention de d~sensibilisation des mouvements oculaires et de retraitement (DMOR)permet de ramener ces structures c~r6brales A un mode de fonctionnement normal et derdduire les sympt~mes du SSPT. Comme la relation entre le traitement DMOR et leschangements dans les structures c~r6brales qui seraient li~es aux sympt6mes du SSPT n'a pasW 6tablie, il est difficile de justifier l'utilisation de la d6sensibilisation des mouvements

0 oculaires et du retraitement pour 6tudier les changements dans ces structures cdrdbrales. Deplus, m~me si la cartographie des changements dans les structures c6r~brales comportecertains avantages scientifiques, ii serait plus appropri6 de faire appel A d'autres organismes definancement pour financer les recherches sur les processus de neurosciences 6ldmentairesassoci~s au fonctionnement du cerveau dans le cas du SSPT (par exemple, le CRSNG ou lesIRSC).

Thompson, M.M., Past6, L., McCreary, D.R.. 2002. Empirical assessment of Lanius et al.s' 'Functional MRI ofEMDR in Peacekeepers', a review of the EMDR literature and an annotated bibliography. DRDC Toronto TM 2002- 025 DRDC Toronto.

DRDC Toronto TM 2002-025 v

0

Efficacit6 th6rapeutique de la desensibilisation desmouvemnents oculaires et du retraitemnent.

Un survol des 6tudes effectudes sur le traitement DMOR montre que l'efficacit6 de cetteth6rapie suscite beaucoup de controverse. En g6n~ral, l'examen des publications portant surles recherches empiriques en DMOR ont montr6 ce qui suit:

1 . La d~sensibilisation des mouvements oculaires et le retraitement constituent un traitementefficace seulement lorsque l'on compare des sujets ayant requ ce traitement A des patientsn'ayant requ aucun traitement, A des patients qui sont sur une liste dtattente ou encore Ades patients qui ont requ une th~rapie non sp~cifique (par exemple, r~troaction biologiqueet relaxation);

2. Le traitement par ddsensibilisation des mouvements oculaires et retraitement nWest pas une6th~rapie plus efficace que les th~rapies d'exposition, y compris la m~thode d'inoculationcontre le stress, les techniques de th~rapie cognitive et l'exposition prolong6e;

3. Les mouvements oculaires ou encore tout autre stimulus (par exemple, lefinger tapping)ne sont pas responsables des bienfaits dui traitement.

1ttant donn6 la controverse qui entoure l'efflcacit6 de la d~sensibilisation des mouvementsoculaires et dui retraitemnent, il ne semble pas prudent de financer des recherches qui seraientbasses sur l'application du traitement DMOR A des memnbres du personnel des FC souffrant duSSPT, qui avaient 6t6 affect~s i des activit~s de maintien de la paix.

Appui financier demand.6 : Les points suivants relatifs A la nature et A la valeur en dollars decertains postes de la demande d'appui financier exigent des 6claircissements.

1 . Il nWest pas pr~cis6 sur quoi les auteurs se sont fond~s pour 6tablir les frais d'6valuationpsychiatrique (1200 $ par 6valuation).

2. Il faudrait indiquer l'identit6 des personnes qui, selon le budget, recevraient uner6mun~ration pour effectuer diverses composantes du projet, surtout si ces personnes sontaussi des auteurs de la proposition.

Conclusions:

Cette 6tude a, comme principaux objectifs, d'effectuer une recherche fondamentale plut6t quede chercher i am~1iorer N'tat des memnbres du personnel des FC souffrant du SSPT, quiavaient 6t affect~s A des activit~s de maintien de la paix. Par cons6quent, il semnble qu'il0serait plus appropri6 de faire appel A d'autres organismes de financement pour ces travaux.L'efficacit6 de la d~sensibilisation des mouvements oculaires et du retraitement semble lire Ases composantes exposition et reformulation cognitive, et non aux mouvements oculaires.Ainsi, l'utilisation du traitement DMOR ne donnera aucun rdsultat th6rapeutique sup~rieur auxr~sultats des th6rapies de traitemnent du SSPT qui sont 6tablies et ont 6t6 valid6s parexp~rience. Certains aspects du budget propos6 ne sont pas clairs. Il ne semnble pas prudentpour le moment d'investir dans cette proposition de recherche.

Vi DRDC Toronto TM 2002-025

Table of contents

Abstract ....................................................................................................................................... i

R6sum 6 ........................................................................................................................................ i

Executive summ ary ................................................................................................................... iii

Research goals: ............................................................................................................. iii

Therapeutic effectiveness of EM DR ........................................................................ iii

Conclusion ..................................................................................................................... iv

Som m aire .................................................................................................................................... v

Objectifs de la recherche : ........................................................................................ v

Efficacit6 th6rapeutique de la d6sensibilisation des mouvements oculaires et duretraitem ent ................................................................................................................... vi

Conclusions: .................................................................................................................. vi

'Table of contents ...................................................................................................................... vii

Review of "Functional MRI of EMDR for PTSD in Peacekeepers" .......................... 1

Research goals ........................................................................................................ 1

General comm ents ..................................................................................................... 2

SEM DR literature review ...................................................................................................... 3

Requested financial support ..................................................................................... 3

Recom m endations ..................................................................................................... 4

A critical review of EM DR research ..................................................................................... 7

Overview of literature review ................................................................................... 7

References ................................................................................................................................. 11

* Appendix A: Selected annotated bibliography of EMDR research reviews ........................ 13

M eta-analysis ............................................................................................................... 13

Review s ........................................................................................................................ 13

EM DR vs. Specific Treatm ents ............................................................................... 18

EM DR with and without eye m ovem ents .............................................................. 19

Dism antling Study ................................................................................................... 20

DRDC Toronto TM 2002-025 Vii

I

6

6


6

6

6

6

6

6

0

viii DRDC Toronto TM 2002-025

6

Review of "Functional MRI of EMDR for PTSD inPeacekeepers".......e.e. .r..,.'....................................................................................................................................................................................... ............................................................................................ ...... ....... ....... ............

The following is a review of a grant proposal submitted to the Department of NationalDefence (DND) by Dr. Ruth A. Lanius and co-investigators, Dr. Donald Richardson, Dr.Sandra Wilson, Dr. James Hopper, and Dr. Peter Williamson. Several issues are addressed inthe following review of this proposal, including the applicability of the research to DNDpriorities, the controversy surrounding Eye Movement Desensitization and Reprocessing(EMDR) as a clinical tool, and specific questions arising from the submitted budget.

Research goals

The purposes of the proposed research are: (1) to study EMDR as a treatment forpeacekeeping-related PTSD; (2) to study the impact of PTSD (Post Traumatic StressDisorder) on subjective distress during recall of traumatic memories and on limbic,paralimbic, and prefrontal brain structures using functional MRI (Magnetic ResonanceImaging); and (3) to determine whether an EMDR intervention causes those structures toreturn to their normal mode of functioning, while also reducing PTSD symptomatology.

The investigators plan on recruiting 60 participants who have experienced peacekeepingduties and have been exposed to traumatic stressors during their tour(s) of duty. Of thosesubjects, 40 will be physician-diagnosed with PTSD, while the remaining 20 will not meet thediagnostic criteria for PTSD. The 40 participants with a PTSD diagnosis will be divided intotwo groups of 20. One group will receive EMDR (Eye Movement Desensitization andReprocessing) as treatment for their PTSD, while the other group will comprise awaitlist/routine clinical care comparison group.

All participants will undergo an initial psychometric assessment and fMRI scanning. It isexpected that the fMRI results will show no limbic, paralimbic, or prefrontal brain structureactivation differences between the two PTSD groups, but that differences will exist in theseareas between each of the two PTSD groups, and the non-PTSD group.

The PTSD-EMDR group will undergo 15 sessions of EMDR treatment over an 8-weekperiod. They will receive an fMRI scan immediately following completion of the treatment,and again six months later. The PTSD-waitlist group will undergo an fMRI at approximatelythe same time as the PTSD-EMDR group is completing their post-treatment fMRI (i.e., 8weeks after initial assessment). The PTSD-waitlist group will not undergo a six-monthfollow-up fMRI.

This intervention is designed to ascertain whether EMDR treatment has a significant impactupon limbic, paralimbic, and prefrontal brain structures. If this is the case, then the 8-weekpost-treatment fMRIs should show (1) changes from the baseline fMIRI for the EMDR group,but not for the waitlist group, and (2) significant post-treatment differences between the twoPTSD groups when there were none at the pre-treatment stage. Furthermore, the post-treatment and six-month follow-up fMRIs for the PTSD-EMDR group should be similar to


0

the flMfRIs for the non-PTSD control group because it is expected that the treatment shouldrepair brain structure activation to what it had been prior to the development of PTSD.

General comments

1. The investigators have linked their research agenda with an issue of major concern toDND (i.e., PTSD and its treatment). Indeed, the study of EMDR as a treatment forpeacekeeping-related PTSD was listed as the first aim of the project (page 3). However,the specific PTSD-EMDR treatment aspect is actually a relatively secondary issuethroughout the proposal. Indeed, EMDR is chiefly used to provide supporting evidence ofa link between PTSD and the functioning of specific brain areas. That is, if effectivetreatment of PTSD were related to a return to normal functioning in the brain structurespresumed to mediate PTSD symptomatology, then the hypothesis that PTSD is relatedwith functioning in these brain areas is strengthened. The authors' note that there are nopublished reports of the relation between EMDR treatment and changes among the brainstructures presumably identified with PTSD symptomatology. It is difficult, therefore, tojustify the use of EMDR in this context. Moreover, there is significant controversy thatsurrounds the use of EMDR as a treatment of PTSD (see EMDR Literature Reviewbelow).

2. The major objective of the proposed study then, is to assess the impact of PTSD (PostTraumatic Stress Disorder) on limbic, paralimbic, and prefrontal brain structures usingfunctional MRI (Magnetic Resonance Imaging) and to determine whether an EMDRintervention causes those structures to return to their normal mode of functioning, whilealso reducing PTSD symptomatology.

More specifically, this research explores the relation between PTSD and brain structureactivation using fMRI, or as the authors' state "[do] pathological responses to trauma-relatedstimuli impair cognitive control and associated prefrontal activation?" The authors havedocumented the research linking PTSD with limbic, paralimbic, and prefrontal structures.They also have presented a sound rationale for exploring further this link with script drivenimagery, as well as the advantages of using a more powerful (4 Telsa) fMRI.

While these objectives may have scientific merit, it is not clear that the Department ofNational Defence is the appropriate funding body for basic research on this issue. There areseveral funding agencies whose mandates may be more appropriate for investigations of basicneuroscience processes associated with brain functioning in PTSD (e.g., NSERC or CIHR).

2 DRDC Toronto TM 2002-025

S

EMDR literature review

In several instances, the proposal concludes that EMDR is an effective therapeuticintervention for PTSD. For instance, the authors state that EMDR was recently recommendedas an "effective treatment for PTSD in the Practice Guidelines of the International Society forTraumatic Stress Studies (Foa et al., 2000). "(Richardson, Wilson, Hopper & Williamson,2001, p. 4).

A survey of the EMDR literature makes apparent that the proposal provides an unbalancedassessment of the therapy. The investigators failed to review the entire EMDR researchliterature; appearing to focus only on the studies that suggest EMDR is effective. A thoroughliterature review, however, would show that there is a great deal of controversy remainsconcerning this therapy. In general the empirical literature is much less supportive of EMDRas a recognized therapy. For instance, a closer examination of the cited reference suggestingthat EMDR is recommended as an effective treatment of PTSD indicates that EMDR is onechapter in a book summarizing PTSD therapies (Chemtob, Tolin, van der Kolk, & Pitman,2000). This chapter summarizes EMDR procedures but also discusses dismantling researchthat casts doubt on the therapeutic benefits of the rapid eye movement component of thetherapy. Overall, reviews of the empirical EMDR literature (see Cahill, Carrigan, & Freuh,1999; Davidson & Parker, 2001; Herbert, Lilienfeld, Lorh, Montgomery, O'Donohue, Rosen,& Tolin, 2000; Hudson, Chase, & Pope, 1998; Shepherd, Stein, & Milne, 2000) conclude that

1. EMDR is an effective treatment only when compared to no treatment or waitlist controlsor to non-specific therapies (e.g., biofeedback, relaxation);

2. EMDR is not more effective than exposure-based therapies, including stress inoculation,cognitive therapy techniques and prolonged exposure;

3. Eye movements, or indeed any other alternating stimuli (e.g. therapist finger tapping) arenot responsible for treatment benefits.

A more complete summary of the EMDR literature contained in these reviews is provided inAppendix A, while an annotated bibliography of the recent EMDR review papers is given inAppendix B.

Requested financial support

The investigators are requesting $439,328 in order to complete this project. This is amethodologically and logistically complex project, requiring each subject to commit to morethan 8-months of participation in one form or another.

However, there are several concerns with regard to the nature and dollar value of specificitems in the request for financial support.

1. A very large proportion of the anticipated budget for the project is allocated to psychiatricassessments. Of the total $439,328 requested, $168,000 or just over 38% of the budget is

DRDC Toronto TM 2002-025 3

allocated to the psychiatric assessments both of the treatment and of the control subjects.From the procedures section of the report, it appears that each of the anticipated 40 PTSDsubjects is assessed on three separate occasions, and each of the anticipated 20 controlsubjects is assessed on one occasion. The budget allocated to each assessment session is$1,200. The most labour intensive assessment session appears to be the first one. In thefirst session, the Coordinator/Interviewer administers or assesses each subject on 8measures, and then gathers information for generating personal trauma-related scripts. Itwould be very helpful if some indication were given with regard to the anticipatedduration of the first session. Even at $250 per hour, the cost the authors budgeted for eachtherapy session, $1,200 should pay for almost a 5-hour assessment session. In the secondassessment session, treatment-related measures are administered again at a cost of $1,200,although this second session does not appear to require the same time commitment as thefirst (i.e., the SCID-1 and SCID-II structured interviews are not administered, andpersonal trauma-related scripts are not generated). This same issue arises for both thepost-treatment and the 6-month post-treatment assessments. In sum, it appears unclear onwhat bases the authors have allocated costs for the psychiatric assessments. It is commonin this sort of research for self-report measures to be administered by trained researchassistants, and that qualified (i.e., PhD or MD level) professionals administer onlystructured clinical interviews. Thus, a research assistant, at a substantial cost saving, couldadminister many of the initial and follow-up assessment tools.

2. The second issue is related to the first. It is unclear from the proposal who will conductthe psychiatric assessments. The authors write that the first session will be conducted bythe study Coordinator/Interviewer. Does the same person also conduct subsequentassessment sessions? Is the study Coordinator/Interviewer one of the authors of theproposal? The identities of the individuals budgeted to receive remuneration forcompleting various components of the project should be specified, particularly if theseindividuals are also the authors of the proposal. The requested financial support alsobudgets for a Subject Coordinator. Again, is this person hired specifically for this purposeor will this position be filled by one of the investigators? The authors also need to specifywhat the anticipated duration of this position is. According to NSERC and CIHRguidelines, post-docs (who often serve as study/subject coordinators) are typically paidbetween $35,000 and $40,000 for one year of full-time work.

3. Among the Subject Coordinator's responsibilities is the analysis of clinical data. Howdoes this specific responsibility differ from data analyses? This is important as dataanalyses for both the control and therapy groups receive separate budget allocations. Atotal of $60,000, almost 14% of the total budget, is allocated for data analyses. Theproposed project does involve the collection of a large amount of data. However, thisamount of money would typically pay for the full-time statistical services of a dedicatedassistant for well over a year. It is not clear that the data analyses for the proposed projectwould require more than 4 months of full-time work.

Recommendations

1. In light of the controversy regarding the effectiveness of EMDR as a treatment for PTSD,alternative control groups appear warranted. At a minimum, EMDR should be compared


to other specific therapeutic protocols for PTSD. For example, there are effective,empirically validated cognitive and cognitive-behavioural therapies for PTSD that seemquite appropriate options in this respect.

An alternate empirical approach would be to systematically investigate the relative therapeuticeffectiveness of each component of EMDR (referred to as a dismantling study). For example,complete EMDR treatment could be compared with one that does not include the eyemovements component, and with another treatment that does not include other aspects ofEMDR (e.g., the positive cognition component). This approach would assess which, if any, ofthe major components of EMDR are associated both with brain function and with relievingPTSD symptomatology.

2. The proposal demands both significant time and psychic involvement of the militarypersonnel who serve as participants in this research. Although several measures ofpsychological and interpersonal functioning are used as intake and trauma-relatedassessment measures, changes on these measures appear to be addressed in a somewhatcursory way in the hypotheses. This is unfortunate as these sorts of outcomes presumablywould be of most value and relevance to military personnel experiencing the debilitatingeffects of PTSD. Thus, the proposal might more obviously concern itself with outcomeslinked to the psychological and interpersonal functioning and recovery. Such refocusingwould demonstrate that the aims of this research are more fundamentally tied to importantlong-term quality of life issues of Canadian Forces military personnel suffering frompeacekeeping-related PTSD.


6

6

6


a

6

6

6

6

a

0


6

A critical review of EMDR research

Overview of literature review

For the purposes of this literature review, approximately 200 abstracts concerning EyeMovement Desensitization and Reprocessing (EMDR) therapy were surveyed usingPsychInfo and MedLine databases.

Particular emphasis was placed on reviews of experimental research directly comparingEMDR with other therapies and to meta-analyses of EMDR studies (see Appendix B). Thefollowing journals were surveyed: Journal of Consulting and Clinical Psychology, ClinicalPsychology Review, Journal of Anxiety Disorders, Journal of Behavior Therapy andExperimental Psychiatry, and the Journal of Traumatic Stress.

EMDR is a relatively recently developed procedure for the treatment of traumatic memoriesand related conditions (Shapiro, 1989a; 1989b). According to Shapiro, psychopathology is theresult of dysfunctionally stored information (Herbert et al., 1999). According to Shapiro, rapideye movements facilitate the emotional processing of trauma. The rapid eye movementtechnique that has received the most attention and credit for therapeutic improvementsassociated with EMDR is actually administered as a component of a much broader therapeuticprocedure (Tallis & Smith, 1994). Thus, EMDR is typically a structured, client-centred modelthat actually combines intrapsychic, behavioural, cognitive, body-oriented, and interactionalapproaches (Shapiro, Vogelmann-Sine, & Sine, 1994). EMDR typically entails 8 therapeuticcomponents including sequential exposure, desensitization, cognitive restructuring, rehearsaland classical conditioning (Shapiro, 1996).

EMDR has aspects that make it appear to be a desirable therapeutic alternative, for instance,its applicability to a wide-variety of psychological disorders including PTSD, phobias, panicdisorders, and eating disorders (Hudson, Chase, & Pope, 2000).

Particularly impressive are its claims of positive, permanent and dramatic effects in relativelyfew sessions (Shapiro, 1996). EMDR was also recently adopted as a 'probably efficacioustreatment for PTSD' by Division 12 of the American Psychological Association, also lendingconsiderable apparent credibility to the technique (Herbert et al., 1999).

As compelling as claims concerning EMDR are, the underlying mechanisms responsible fortherapeutic improvements remain unclear. Shapiro, the originator of the EMDR (see Shapiro,1996; 1996b; Shapiro et al., 1994), proposes that rapid eye movements stimulate an inherentphysiological processing system that allows dysfunctional information to be adaptivelyresolved, resulting in increased insight and more functional behaviour. The rapid eyemovements are assumed to weaken the neural links between the traumatic stimulus andemotional response, thereby restoring balance. However, the exact mechanisms implicatedhere are not described in any more detail. Moreover, the proceeding account is not consistentwith any established "physiological or neurological phenomenon [and thus does not provide]a compelling theoretical rational for EMDR" (Hudson et al., 2000, p. 3).


0

A related hypothesis suggests the basis of EMDR effects lies with the investigatorycomponent of the orienting reflex, an evolutionary development enabling organisms to assesstheir environment for both rewards and dangers. EMDR is thought to promote conditioningwhereby the positive visceral element of the investigatory reflex, presumably the eyemovements themselves, is paired with clinically-induced noxious memories thereby removingassociated negative affect (MacCulloch & Feldman, 1996). The question becomes whether theconditioning that is the presumed basis of change is predicated on the eye movements orwhether any pairing of negative memories to positive stimuli might produce similar beneficialeffects.

A further suggestion is that the rapid eye movements are similar to those produced duringREM sleep which, in psychoanalytic theory, has been associated with a working through oftroubling life events (Hudson et al., 2000). Unfortunately, there is no empirical evidence tosupport the claim that the rapid eye movements are more than correlates of psychic workingthrough that may occur with REM states or that the eye movements of EMDR are equivalentto those of REM states. Moreover, there is no empirical evidence linking dream states totherapeutic effects, and certainly not to benefits that exceed those experienced in wakingstates (Hudson et al., 2000).

A final hypothesis offered by proponents of EMDR is that non-specific factors associatedwith the treatment such as human contact, focus on traumatic experiences, distraction and/orrelaxation account for beneficial therapeutic effects (Hudson et al., 2000). While positiveeffects of EMDR may well be attributable to these components, they tend to prove the pointthat positive results are the product of techniques equally associated with other therapies andthat the eye movement component of the therapy is superfluous.

Several excellent scholarly reviews of the EMDR literature exist (Cahill, Carrigan, & Frueh,1999; Cusak & Spates, 1999; Herbert, Lilienfeld, Lorh, Montgomery, O'Donohue, Rosen, &Tolin, 2000; Hudson, Chase, & Pope, 1998). While one review suggests that the initialevidence concerning EMDR is encouraging (Shepard, Stein, & Milne, 2000), most reviewsconclude that EMDR offers no therapeutic benefits over that of traditional and empiricallyestablished exposure and cognitive behavioural treatments for PTSD (Cahill et al., 1999;Herbert et al., 2000). These conclusions are supported by the results of a meta-analysis(Davidson & Parker, 2001), a technique that provides an empirical evaluation of a researcharea by examining the size of treatment effects across groups of studies.

First of all, it is important to note that most reviews indicate that a great deal of EMDRresearch is poorly designed or inappropriately analyzed, or is based upon case study results(Cahill et al, 1999; Herbert et al., 2000). Reviews of more rigorous scientific research suggestthat EMDR does provide significant relief from psychological distress relative to no treatmentor to wait list control conditions. The beneficial effects of EMDR are most evident in so-called process measures; that is self-report measures of distress assessed during therapy suchas the Subjective Units of Discomfort (SUDS) and the Validity of Cognitions (VOC) scales.There is less evidence of EMDR's effectiveness at the level of outcome, that is behavioural orphysiological indices of distress associated with trauma. Moreover, the literatureoverwhelmingly concludes that EMDR does not provide therapeutic benefits above those ofexposure-based and cognitive behavioural treatments. In particular, the meta-analysisconducted Davidson and Parker (2001) revealed that, across studies, the eye movement


component of EMDR, the supposed basis of the therapy, produced near-zero effects whencompared with studies that did not include the eye movement component. Dismantlingstudies, those that systematically vary components of therapies, also confirm the lack of effectof eye movement components. Unfortunately, although the critical components of EMDR,namely rapid eye movements (or other lateral stimulation such as therapists' finger tapping,light bars or sound generators) fail to account for the beneficial effects of the therapy, asCusak and Spates (1999) note that these same elements have nevertheless enteredunparsimoniously as explanatory variables for the therapy.

In sum, then, it is exceedingly difficult to disagree with the following commentary concerningEMDR:

"When experimental research consistently demonstrates that EMDR withouteye movement or lateral stimulation is as effective as the fill treatmentprocedure, it is no longer reasonable for clinicians to learn the clinicalintricacies of their hand movements (or the use of automated flashing lightbars or sound generators) while misinforming their clients that they canexpect accelerated information processing as a consequence" (Herbert et al.,2000, p. 964-965).


6

6

6


6

6

I

6

6

6

a


6

References

Cahill, S.P., Carrigan, M.H., & Frueh, B.C. (1999). Does EMDR work? And if so, why?: Acritical review of controlled outcome and dismantling research. Journal of AnxietyDisorders, 13, 5-33.

Cusak, K. & Spates, C.R. (1999). The cognitive dismantling of eye movement desensitizationand reprocessing (EMDR) treatment of posttraumatic stress disorder (PTSD). Journal ofAnxiety Disorders, 13, 87-99.

Davidson, P.R., & Parker, K.C.H. (2001). Eye movement desensitization and reprocessing(EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-316.

Goldstein, A.J., de Beurs, E., Chambless, D.L., & Wilson, K.A. (2000). EMDR for panicdisorder with agoraphobia: Comparison with waiting list and credible attention-placebocontrol conditions. Journal of Consulting and Clinical Psychology, 68, 947-956.

Herbert, J.D., Lilienfeld, S.O., Lorh, J.M., Montgomery, R.W., O'Donohue, W.T., RosenG.M., & Tolin, D.F. (2000). Science and psuedoscience in the development of eyemovement desensitization and reprocessing: Implications for clinical psychology.Clinical Psychology Review, 20, 945-971.

Hudson, J.I., Chase, E.A., & Pope, H.G. (1998). Eye movement desensitization andreprocessing in eating disorders: Caution against premature acceptance. InternationalJournal of Eating Disorders, 23, 1-5.

MacCulloch, M.J., & Feldman, P. (1996). Eye movement desensitization treatment utilizedthe positive visceral element of the investigatory reflex to inhibit the memories of post-traumatic stress disorder: A theoretical analysis. British Journal of Psychiatry, 169,571-579.

Muris, P., & Merckelbach, H. (1999). Traumatic memories, eye movements, phobia, andpanic: A critical note on the proliferation of EMDR. Journal of Anxiety Disorders, 13,209-223.

Shapiro, F. (1989). Eye movement desensitization procedure in the treatment of traumaticmemories. Journal of Traumatic Stress, 2, 199-223.

Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-traumatic stressdisorder. Journal of Behavior Therapy & Experimental Psychiatry, 20, 211-217.

Shapiro, F. (1996). Eye movement desensitization and reprocessing: Evaluation of controlledPTSD research. Journal of Behavior Therapy and Experimental Psychiatry, 27, 209-


218.

Shapiro, F. (1 996b). Errors of context and review of eye movement desensitization andreprocessing research. Journal of Behavior Therapy and Experimental Psychiatry, 27,313-317.

Shapiro, F., Vogelmann-Sine, S., & Sine, L. (1994). Eye movement desensitization andreprocessing: Treating trauma and substance abuse. Journal of Psychoactive Drugs, 26,379-391.

Shepherd, J., Stein, K., & Milne, R. (2000). Eye movement desensitization and reprocessingin the treatment of post-traumatic stress disorder: A review of an emerging therapy.Psychological Medicine, 30, 863-871.

Tallis, F., Smith, E. (1994). Does rapid eye movement desensitization facilitate emotionalprocessing. Behaviour Research and Therapy, 32, 459-461.

1 2 DRDC Toronto TM 2002-025

Appendix A: Selected annotated bibliography ofEMDR research reviews

Meta-analysis0

1. Davidson, P.R., & Parker, K.C. (2001). Eye movement desensitization and reprocessing(EMDR): a meta-analysis. Journal of Consulting and Clinical Psychology 69, 305-316.

Eye movement desensitization and reprocessing (EMDR), a controversial treatmentsuggested for posttraumatic stress disorder (PTSD) and other conditions, wasevaluated in a meta-analysis of 34 studies that examined EMDR with a variety ofpopulations and measures. Process and outcome measures were examined separately.EMDR showed an effect on both when compared with no treatment and withtherapies not using exposure to anxiety-provoking stimuli and in pre post EMDRcomparisons. However, no significant effect was found when EMDR was comparedwith other exposure techniques. No incremental effect of eye movements was notedwhen EMDR was compared with the same procedure without them. DeRubeis andCrits-Christoph (1998) noted that EMDR is a potentially effective treatment for non-combat PTSD, but studies that examined such patient groups did not give clearsupport to this. In sum, EMDR appears to be no more effective than other exposuretechniques, and evidence suggests that the eye movements integral to the treatment,and to its name, are unnecessary.

Reviews

1. Chemtob, C. M. Tolin, D. F., van der Kolk, B. A. & Pitman, Roger K. (2000). Eyemovement desensitization and reprocessing. In E. B. Foa, T. M. Keane, & M. J. Friedman(Eds.), Effective treatments for PTSD: Practice guidelines from the International Society forTraumatic Stress Studies (pp. 139-154). New York, NY: The Guilford Press.

Provides an overview of the history and theory of eye movement desensitization andreprocessing (EMDR) and summarizes the procedure and provides a review of theoutcome literature concerning its effectiveness for posttraumatic stress disorder (PTSD).EMDR treatment requires the patient to identify multiple aspects of the traumaticmemory, including the images associated with the event, the affective and physiologicalresponse elements, the negative self-representation, induced by the traumatic experience(for PTSD), and an alternate, desired, positive self-representation. EMDR incorporatesthe following 8 stages: patient history and treatment planning, preparation, assessment,desensitization and reprocessing, installation of positive cognition, body scan, closure,and reevaluation. Dismantling studies of the contribution of eye movements to theefficacy of the EMDR procedure are reviewed, followed by an overall rating reflectingthe current knowledge of EMDR's efficacy, along with recommendations for its use.


The reviewed studies are divided into 2 categories: those that employed a wait-listcontrol, and those that employed control treatments. The chapter concludes withsuggestions for further research.

2. J. Shepherd, J., Stein, K., & Milne, R. (2000). Eye movement desensitization andreprocessing in the treatment of post-traumatic stress disorder: a review of an emergingtherapy. Psychological Medicine, 30, 863-871.

Background. Eye Movement Desensitization and Reprocessing (EMDR) is arelatively new form of psychotherapy for post-traumatic stress disorder. We criticallyreviewed randomized controlled trials of EMDR. Methods. A wide range ofelectronic databases and reference lists of articles obtained were searched andrelevant experts were consulted. Studies were critically appraised according toestablished criteria. Results. We found 16 published randomized controlled trials(RCTs) comparing EMDR with alternative psychotherapy treatments, variants ofEMDR and with delayed treatment groups. Studies were generally small (meannumber of patients 35) and of variable methodological quality, with only fivereporting blinding of outcome assessors to treatment allocation, and in some caseswith high loss to follow-up. In most cases EMDR was shown to be effective atreducing symptoms up to 3 months after treatment. In one case benefit wasmaintained up to 9 months and in another (uncontrolled) follow-up treatment effectwas present at 15 months. Two studies suggest that EMDR is as effective as exposuretherapies, three claim greater effectiveness in comparison to relaxation training, andthree claim superiority over delayed treatment groups. Of the studies examiningspecific treatment components, two found that treatment with eyes moving was moreeffective than eyes fixed, while three studies found the two procedures to be of equaleffectiveness. Conclusion. The evidence in support of EMDR is of limited quality butresults are encouraging for this inexpensive, simple therapy. Further research iswarranted in larger samples with longer periods of follow-up.

3. Herbert, J.D., Lilienfeld, S.O., Lohr, J.M., Montgomery, R.W., O'Donohue, W.T., Rosen,G.M., & Tolin, D.F. (2000). Science and pseudoscience in the development of eye movementdesensitization and reprocessing: Implications for clinical psychology. Clinical PsychologyReview, 20, 945-971.

The enormous popularity recently achieved by Eye Movement Desensitizationand Reprocessing (EMDR) as a treatment for anxiety disorders appears to havegreatly outstripped the evidence for its efficacy from controlled research studies.The disparity raises disturbing questions concerning EMDR's aggressivecommercial promotion and its rapid acceptance among practitioners. In thisarticle, we: (1) summarize the evidence concerning EMDR's efficacy; (2)describe the dissemination and promotion of EMDR; (3) delineate the features ofpseudoscience and explicate their relevance to EMDR; (4) describe thepseudoscientific marketing practices used to promote EMDR; (5) analyze factorscontributing to the acceptance of EMDR by professional psychologists; and (6)discuss practical considerations for professional psychologists regarding theadoption of EMDR into professional practice. We argue that EMDR provides an


SII |6

excellent vehicle for illustrating the differences between scientific andpseudoscientific therapeutic techniques. Such distinctions are of criticalimportance for clinical psychologists who intend to base their practice on the bestavailable research.

4. Feske, U. (1998). Eye movement desensitization and reprocessing treatment forposttraumatic stress disorder. Clinical Psychology: Science & Practice, 5, 171-181.

A qualitative review of experimental and quasi-experimental outcome studies (D.Forbes et al, 1994; R. A. Kleinknecht and M. P. Morgan, 1992) of eye movementdesensitization and reprocessing (EMDR) treatment for persons with posttraumaticstress disorder (PTSD) suggests that the treatment is effective for civilian but notcombat PTSD. The current data indicate that additional research into EMDR'sefficacy for PTSD is warranted. Further studies should include comparisons toplacebo control procedures and existing validated treatments for PTSD, an adequatetreatment dose, and systematic efforts to establish and assess treatment integrity andquality, and long-term follow-up data. The therapeutic mechanisms underlyingEMDR's observed benefits remain elusive. Whether the eye movement or some othertype of stimulation is essential to EMDR's effects cannot be determined from thecurrent data.

5. MacCluskie, K.C. (1998). A review of eye movement desensitization and reprocessing(EMDR): Research findings and implications for counsellors. Canadian Journal ofCounselling, 32, 116-137.

Provides a synopsis of the research examining the efficacy of Eye MovementDesensitization and Reprocessing (EMDR). EMDR is most often used to treatsymptoms of posttraumatic stress disorder (PTSD). The research literature pertainingto EMDR falls into 4 categories: pilot studies, uncontrolled case studies, controlledcase studies, and controlled group studies. Each of these categories will besystematically reviewed. This paper also provides overviews/critiques of previouslypublished research, which are cited throughout the descriptions of studies. In additionto the synopsis of the research, readers are offered references for other reviews of theliterature, and a discussion of why this topic has generated such a heated debate.There is also a discussion of the implications of the research findings for counselorsin practice, including how to make sense of the conflicting data and the ethicalimplications of using, or not using, this technique with clients who are suffering fromsymptoms secondary to emotional trauma.

6. Lohr, J.M., Tolin, D.F., & Lilienfeld, S.O. (1998). Efficacy of Eye MovementDesensitization and Reprocessing: Implications for behavior therapy. Behavior Therapy, 29,123-156.

The commitment of behaviour therapy to empiricism has led it to a prominentposition in the development of validated methods of treatment. The recentdevelopment and rapid expansion of Eye Movement Desensitization and


Reprocessing (EMDR), a treatment that bears a resemblance to behaviouraltechniques and that has been proposed as an alternative to such techniques fornumerous psychological disorders, raises important questions for the field ofbehaviour therapy. In this article, we examine 17 recent studies on the effectivenessof EMDR and the conceptual analysis of its mechanisms of action. The research wereview shows that (a) the effects of EMDR are limited largely or entirely to verbalreport indices, (b) eye movements appear to be unnecessary for improvement, and (c)reported effects are consistent with non-specific procedural artifacts. Moreover, theconceptual analysis of EMDR is inconsistent with scientific findings concerning therole of eye movements. Implications of the empirical and theoretical literature onEMDR for behaviour therapy are discussed.

7. Hudson, J.I., Chase, E.A., & Pope, H.G., Jr. (1998). Eye movement desensitization andreprocessing in eating disorders: Caution against premature acceptance. International Journalof Eating Disorders, 23, 1-5.

Reviews the literature to assess the benefits and risks of the use of eye movementdesensitization and reprocessing (EMDR) in the treatment of eating disorders.Looking at the question of its benefits, no methodologically sound studies were foundto show efficacy for EMDR in eating disorders, or, indeed, any psychiatric disorder.A sound theoretical basis for expecting EMDR to be effective was not found. Inadditional, EMDR may have adverse effects. First, EMDR is sometimes used inconjunction with efforts to "recover" memories of traumatic events. But "recoveredmemory" therapy may carry a risk of inducing potentially harmful false memories.Second, use of EMDR may prevent or delay other therapies of established efficacy foreating disorders, such as cognitive behavioural therapy and antidepressants. In light ofthe findings, the risk/benefit ratio of EMDR does not as yet encourage its widespreadacceptance.

8. DeBell, C., & Jones, R.D. (1997). As good as it seems? A review of EMDR experimentalresearch. Professional Psychology: Research & Practice, 28, 153-163.

The article reviews 7 experimental studies that examined eye movementdesensitization and reprocessing (EMDR) treatment. The 7 studies varied greatly intheir complexity, their designs, how treatment effects were measured, and theirresults. Each study is detailed and critically examined. A summary of results isprovided as well as suggestions for clinical application and future research. Inaddition, questions are raised regarding F. Shapiro's (1995) approach to disseminatinginformation about EMDR.

9. Lee, C., Gavriel, H., & Richards, J. (1996). Eye movement desensitization: Past research,complexities, and future direction. Australian Psychologist, 31, 168-173.

This paper reviews the present state of knowledge about the efficacy of eyemovement desensitization and reprocessing (EMDR) as a treatment for traumatic


memories, and draws on information-processing theory to identify basic problemswith much of the research on this procedure. The general failure of this research totake into account the complexity and hypothesised theoretical underpinnings ofEMDR is discussed, and suggestions are made for future research. Although EMDRhas shown some promise as an effective intervention for posttraumatic stress disorder(PTSD), well controlled comparative outcome studies are required to establish itsefficacy before investigation of its active therapeutic components should beundertaken.

10. Shapiro, F. (1996). Eye movement desensitization and reprocessing (EMDR): Evaluationof controlled PTSD research. Journal of Behavior Therapy & Experimental Psychiatry 27209-218.

Provides a comprehensive, up-to-date review of the literature on eye movementdesensitization and reprocessing (EMDR) research in posttraumatic stress disorder(PTSD), encompassing published articles, papers in press, and papers presented atregional and national meetings. Completed controlled studies that have not beensubject to peer scrutiny were excluded. A number of studies are presented that supportEMDR as an empirically validated method, used in the context of other methods, inthe treatment of PTSD. However, in several studies, clinical standards have notalways been integrated with rigorous scientific methodology. The suggested standardsinclude fidelity checks for the method being tested, the use of appropriatepsychometrics, and assessment of co-morbidity factors. At the same time, because ofcommon misconceptions about the method, a variety of problematic issues arediscussed.

11. Cahill, S.P., Carrigan, M.H., & Frueh, B.C. (1999). Does EMDR Work? And if so, Why?A Critical Review of Controlled Outcome and Dismantling Research. Journal of AnxietyDisorders, 13, 5-33.

Research on Eye Movement Desensitization and Reprocessing therapy (EMDR) wasreviewed to answer the questions "Does EMDR work?" and "If so, Why?" This firstquestion was further subdivided on the basis of the control group: (a) no-treatment (orwait list control), (b) nonvalidated treatments, and (c) other validated treatments. Theevidence supports the following general conclusions: First, EMDR appears to beeffective in reducing at least some indices of distress relative to no-treatment in anumber of anxiety conditions, including posttraumatic stress disorder, panic disorder,and public-speaking anxiety. Second, EMDR appears at least as effective or moreeffective than several nonvalidated treatments (e.g., relaxation, active listening) forposttraumatic stress reactions. Third, despite statements implying the contrary, nopreviously published study has directly compared EMDR with an independentlyvalidated treatment for posttraumatic stress disorder (e.g., therapist-directed flooding).In the treatment of simple phobia, participant modeling has been found to be moreeffective than EMDR. Fourth, our review of dismantling studies reveals there is no


convincing evidence that eye movements significantly contribute to treatmentoutcome. Recommendations regarding further research directions are provided.

EMDR vs. Specific Treatments

1. Muris, P., Merckelbach, H., Holdrinet, I., & Sijsenaar, M. (1998). Treating phobic children:Effects of EMDR versus exposure. Journal of Consulting & Clinical Psychology, 66, 193-198.

This study examined the efficacy of eye movement desensitization and reprocessing(EMDR) and exposure in the treatment of a specific phobia. Twenty-six spider phobicchildren were treated during 2 treatment phases. During the first phase, which lasted2.5 hr, children were randomly assigned to either (a) an EMDR group (n = 9), (b) anexposure in vivo group (n = 9), or (c) a computerized exposure (control) group (n8). During the 2nd phase, all groups received a 1.5-hr session of exposure in vivo.Therapy outcome measures (i.e., self-reported fear and behavioural avoidance) wereobtained before treatment, after Treatment Phase 1, and after Treatment Phase 2.Results showed that the 2.5-hr exposure in vivo session produced significantimprovement on all outcome measures. In contrast, EMDR yielded a significantimprovement on only self-reported spider fear. Computerized exposure producednonsignificant improvement. Furthermore, no evidence was found to suggest thatEMDR potentiates the efficacy of a subsequent exposure in vivo treatment. Exposurein vivo remains the treatment of choice for childhood spider phobia.

2. Muris, P., & Merckelbach, H. (1997). Treating spider phobics with eye movementdesensitization and reprocessing: A controlled study. Behavioural & CognitivePsychotherapy, 25, 39-50.

Examined the efficacy of eye movement desensitization and reprocessing (EMDR) inthe treatment of a specific phobia. 24 female spider phobic Ss (aged 24-51 yrs) wererandomly assigned to either (1) an EMDR group (n = 8), (2) an imaginal exposuregroup (n =8), or (3) a control group (n = 8). Both the EMDR and the imaginalexposure group underwent a 1-hr treatment. The control group initially received notreatment, and waited for 1 hr. Next, all groups received exposure in vivo. Treatmentoutcome was evaluated with a standardized Behavioural Avoidance Test. Noevidence was found for EMDR being more effective than imaginal exposure orwaiting list control. In fact, only exposure in vivo therapy resulted in significantimprovement on the behavioural avoidance test.

3. Muris, P., Merckelbach, H., van Haaften, H., & Mayer, B. (1997). Eye movementdesensitisation and reprocessing versus exposure in vivo. A single-session crossover study ofspider-phobic children. British Journal of Psychiatry, 171, 82-86.


i I I •

Compared the efficacy of eye movement desensitization and reprocessing (EMDR)with that of exposure in vivo in the treatment of a specific phobia. 22 spider-phobicfemales (aged 9-14 yrs) who met the Mental Disorders-IIl-Revised (DSM-III-R)criteria for specific phobia participated in the study. Children were treated with onesession of exposure in vivo and one session of EMDR in a crossover design.Treatment outcome was evaluated by self-report measures, a behavioural avoidancetest, and a physiological index (skin conductance level). Results show positive effectsof EMDR, but also suggest that it is especially self-report measures that are sensitiveto EMDR. Improvement on a behavioural measure was less pronounced, andexposure in vivo was found to be superior in reducing avoidance behaviour. Withregard to skin conductance level, EMDR and exposure in vivo did not differ. EMDRhas no additional value in treatment of this type of animal phobia, for which exposurein vivo is the treatment of choice.

4. Grant J.D., & Susan H.S. (1999). The Relative Efficacy and Treatment Distress of EMDRand a Cognitive-Behavior Trauma Treatment Protocol in the Amelioration of PosttraumaticStress Disorder. Journal of Anxiety Disorders, 13, 131-157.

The growing body of research into treatment efficacy with Posttraumatic StressDisorder (PTSD) has, by-and-large, been limited to evaluating treatment componentsor comparing a specific treatment against wait-list controls. This has led to two formsof treatment, Eye Movement Desensitization and Reprocessing (EMDR) andCognitive-Behaviour Therapy (CBT), vying for supremacy without a controlled studyactually comparing them. The present research compared EMDR and a CBT variant(Trauma Treatment Protocol; TTP) in the treatment of PTSD, via a controlled clinical

study using therapists trained in both procedures. It was found that TTP was bothstatistically and clinically more effective in reducing pathology related to PTSD andthat this superiority was maintained and, in fact, became more evident by 3-monthfollow-up. These results are discussed in terms of past research. Directions for futureresearch are suggested.

EMDR with and without eye movements

1. Feske, U., & Goldstein, A.J. (1997). Eye movement desensitization and reprocessingtreatment for panic disorder: A controlled outcome and partial dismantling study. Journal ofConsulting & Clinical Psychology, 65, 1026-1035.

Forty-three outpatients with DSM-III-R (Diagnostic and Statistical Manual of MentalDisorders, 3rd Ed., revised; American Psychiatric Association, 1987) panic disorderswere randomly assigned to receive 6 sessions of eye movement desensitization andreprocessing (EMDR), the same treatment but omitting the eye movement, or to awaiting list. Post-test comparisons showed EMDR to be more effective in alleviating


panic and panic-related symptoms than the waiting-list procedure. Compared with thesame treatment without the eye movement, EMDR led to greater improvement on 2 of5 primary outcome measures at post-test. However, EMDR's advantages haddissipated 3 months after treatment, thereby failing to firmly support the usefulness ofthe eye movement component in EMDR treatment for panic disorder.

2. Hyer, L., & Brandsma, J.M. (1997). EMDR minus eye movements equals goodpsychotherapy. Journal of Traumatic Stress, 10, 515-522.

Eye movement desensitization and reprocessing (EMDR) is a form ofexposure/desensitization therapy roughly equal in efficacy to others currentlyavailable. It is argued that EMDR is efficacious independent of the value of itscomponent parts (e.g., eye movements) and is successful because it applies commonand generally accepted principles of psychotherapy. 10 curative principles of EMDRare discussed as reflective of sound psychotherapy practice. It is hoped that anunderstanding of EMDR from the perspective of the practice and theory ofpsychotherapy will assist in its study.

3. Dunn, T.M., Schwartz, M., Hatfield, R.W., & Wiegele, M. (1996). Measuring effectivenessof eye movement desensitization and reprocessing (EMDR) in non-clinical anxiety: A multi-subject, yoked-control design. Journal of Behavior Therapy & Experimental Psychiatry 27231-239.

Examined the efficacy of eye movement desensitization and reprocessing (EMDR) ina controlled setting to determine if it would be more effective in reducing stress in 28college students who were paired on sex, age, severity, and type of stressful ortraumatic incident. One S in each pair was selected to receive EMDR; theexperimental partner spent the same amount of time receiving a visual (non-movement) placebo. Subjective units of discomfort scores and physiologicalmeasurements were taken prior to and following treatment. Analysis of physiologicalmeasurements and self-reported levels of stress were performed within and betweeneach group. Results show that while the EMDR group showed significant reductionsof stress, EMDR was no better than a placebo. This suggests EMDR's specificintervention involving eye movement may not be a necessary component of thetreatment protocol.

Dismantling Study

1. Cusack, K., & Spates, C.R. (1999). The Cognitive Dismantling of Eye MovementDesensitization and Reprocessing (EMDR) Treatment of Posttraumatic Stress Disorder(PTSD). Journal of Anxiety Disorders, 13, 87-99.


Twenty-seven subjects were exposed to standard Eye Movement Desensitization andReprocessing (EMDR) treatment or a similar treatment without the explicit cognitiveelements found in EMDR. Standardized psychometric assessments were ad-ministered (Structured Interview for Post Traumatic Stress Disorder, Impact of EventScale, Revised Symptom Checklist-90) by independent assessors at pre-test, post-testand two separate follow-up periods. Potential subjects met specificinclusion/exclusion criteria. Subjective measures including Subjective Units ofDisturbance and Validity of Cognition assessments were also conducted. A two-factorrepeated measures analysis of variance revealed that both treatments producedsignificant symptom reductions and were comparable on all dependent measuresacross assessment phases. The present findings are discussed in light of previousdismantling research that converges to suggest that several elements in the EMDRprotocol may be superfluous in terms of the contribution to treatment outcome. Thesesame elements have nevertheless entered unparsimoniously into consideration aspossible explanatory variables.


DOCUMENT CONTROL DATA SHEET

la. PERFORMING AGENCY 2. SECURITY CLASSIFICATION

DRDC Toronto UNCLASSIFIEDUnlimited distribution -

lb. PUBLISHING AGENCY

DRDC Toronto

3. TITLE

(U) EMPIRICAL ASSESSMENT OF LANIUS ET AL.S' 'FUNCTIONAL MRI OF EMDR IN PEACEKEEPERS', AREVIEW OF THE EMDR LITERATURE AND AN ANNOTATED BIBLIOGRAPHY

"4. AUTHORS

Megan. M. Thompson Luigi Past6 Donald R. McCreary

5. DATE OF PUBLICATION 6. NO. OF PAGES

June 1 , 2002 31

7. DESCRIPTIVE NOTES

8. SPONSORING/MONITORING/CONTRACTING/TASKING AGENCYSponsoring Agency:Monitoring Agency:Contracting Agency:Tasking Agency:

9. ORIGINATORS DOCUMENT 10. CONTRACT GRANT AND/OR 11. OTHER DOCUMENT NOS.NO. PROJECT NO.

Technical Memorandum TM 2002-025

12. DOCUMENT RELEASABILITY

Unlimited distribution

I 13. DOCUMENT ANNOUNCEMENT

14. ABSTRACT

(U) This report reviews a research proposal, the major objective of which is to assess the relation between PTSD (PostTraumatic Stress Disorder) and limbic, paralimbic, and prefrontal brain function as assessed with functional MRI(Magnetic Resonance Imaging), and to determine whether an Eye Movement Desensitization and Reprocessing(EMDR) intervention causes those structures to return to a normal mode of functioning. The proposed studysecondarily explores the effectiveness of EMDR in reducing PTSD symptomatology. While the first and secondobjectives of the study may have scientific merit, the mandates of other funding agencies would appear to be moreappropriate for investigations of basic neuroscience processes associated with brain functioning in PTSD (e.g., NSERCor CIHR). Importantly, a critical review of the EMDR research reveals that a great deal of controversy surrounds theeffectiveness of this therapy. EMDR has not been shown to be more effective than presently validated PTSD exposure-based therapies, and the eye movement component of EMDR appears to provide no therapeutic benefit. Finally, thereis a lack of clarity around specific items listed in the proposed budget. Given these concerns it is not recommended thatthis proposal be funded at this time.

(U) Le present rapport passe en revue une proposition de recherche, dont l'objectif premier est d'6valuer la relationentre le SSPT (syndrome de stress post-traumatique) et les fonctions c~rrbrales limbiques, paralimbiques etprrfrontales, en utilisant F'IRM fonctionnelle (imagerie par r6sonance magnrtique), et de determiner si le traitement ded~sensibilisation des mouvements oculaires et de retraitement (DMOR) permet A ces fonctions de revenir A un mode defonctionnement normal. L'6tude proposee explore aussi l'efficacit6 de la d6sensibilisation des mouvements oculaires etdu retraitement pour r~duire les symptrmes du SSPT. M~me si le premier et le second objectifs de l'6tude peuventavoir des avantages scientifiques, d'autres organismes de fmancement sembleraient plus appropri~s pour fmancer larecherche sur les processus de neurosciences 6lmentaires associrs au fonctionnement du cerveau lors du SSPT (parexemple, le CRSNG ou les IRSC). Fait important, une revue critique de la recherche sur la drsensibilisation desmouvements oculaires et le retraitement r~v~le que ce traitement suscite beaucoup de controverse. I1 n'a pas 6t6d~montr6 que la d~sensibilisation des mouvements oculaires et le retraitement constituent un traitement plus efficacedu SSPT que les th6rapies d'exposition actuellement utilis6es A cette fin, et la composante mouvements oculaires dutraitement DMOR ne semble avoir aucun effet thrrapeutique. Enfin, il y a un manque de clart6 en ce qui concemecertains postes inscrits au budget propos6. Etant donn6 ces probl~mes, il n'est pas recommand6 de financer cetteproposition pour le moment.

15. KEYWORDS, DESCRIPTORS or IDENTIFIERS

(U) Post Traumatic Stress Disorder; Magnetic Resonance Imaging; Eye Movement Desensitization and Reprocessing

Defence R&D Canada R & D pour la defense Canada

Canada's leader in defence Chef de file au Canada en R & Dand national security R&D pour la defense et la s~curit6 nationale

A0

DEFENCE 5D DFEFENSE

www.drdc-rddc.gc.ca

empirical assessment of lanius et al.s' 'functional mri of emdr in

Documents